SUMMARY BackgroundPoor adherence to Hepatitis C virus (HCV) treatment is an important cause of treatment failure. Traditional ribavirin 200 mg (RBV) treatment is associated with a significant daily pill burden. RibaPak (RBP), available as 400 mg and 600 mg ribavirin tablets, offers simplified dosing at two pills daily.

The opioid epidemic in the United States has led to increases in hepatitis C virus (HCV) infection especially in rural communities. It is recommended that persons who inject drugs undergo screening and treatment. We initiated HCV screening and treatment within a mostly rural area of Pennsylvania by targeting medicated-assisted treatment (MAT) facilities and community events. Screening was conducted in 43 rural and 13 urban counties by a clinical team. At MAT facilities, the clinical team performed HCV screening between 4:30 am and 1:00 pm using the OraQuick HCV test free of charge. Participants with a positive screen were linked to treatment. In all, 3,051 screening tests were conducted among 2,995 unique participants, who were mostly white (2821, 94%) and from rural counties (2597, 87%). Participants were most frequently 25-to-34 years old (798, 27%). A total of 730 patients were HCV screen positive, 371 patients received an HCV RNA PCR test, and 272 were HCV RNA positive. Of them, 249 met with a healthcare provider, 102 initiated treatment, and 50 completed SVR testing, with 49 achieving SVR. Anti-HCV positivity was more frequent among MAT facility versus non-MAT patients (41% versus 5%) ( p < .001). Non-MAT participants were more likely to begin treatment for HCV (91% [21/23] versus 30% [81/272]) and achieve SVR (71% versus 43%). In HCV screening and treatment among high-risk patients, substantial numbers of participants were lost at every point of care between screening and follow-up testing. Specific screening, treatment, and follow-up strategies for persons in rural communities may be needed.

Background:Pegloticase is indicated for treating uncontrolled gout, but some patients develop anti-drug antibodies that have been associated with a loss of efficacy and infusion reactions (IRs).1 Per the pegloticase prescribing information, pre-infusion medications, including glucocorticoids (GCs), should be given to minimize IR risk.2 Given that GCs have a significant side effect profile and patients with uncontrolled gout generally have multiple comorbidities,3,4 minimizing steroid exposure is desirable.Objectives:The current case series examines a community rheumatology practices’ experience with pre-infusion GC elimination in uncontrolled gout patients treated with pegloticase.Methods:This retrospective chart review was conducted at a rheumatology practice that discontinues pre-infusion GC use in patients treated with pegloticase. Patients treated from 2016-2020 who had pre-infusion GCs discontinued during therapy were included. Pre-infusion prophylaxis at this practice includes methylprednisolone (125 mg IV), diphenhydramine (50 mg oral + 12.5 mg IVP), famotidine (40 mg oral), and acetaminophen (1000 mg) administered immediately before infusions. All other IR prophylaxis continued when GCs were stopped without tapering. Demographics, number of pegloticase infusions, and safety (adverse events [AEs], clinical lab values) were examined. Patients self-managed gout flares with oral methylprednisolone (24 mg then 5-day taper).Results:Nine patients (8 male) with tophaceous gout met inclusion criteria. Mean age was 72.3 ± 6.9 years (65-84 years), mean BMI was 28.7 ± 5.6 kg/m2, and mean pre-therapy serum uric acid (sUA) was 7.3 ± 2.7 mg/dL (3.9-12.7 mg/dL). Two patients were co-treated with oral methotrexate (15 and 20 mg/week) and one patient was on hemodialysis. Most common comorbidities included osteoarthritis (9 patients), hypertension (8 patients), chronic kidney disease (5 patients), kidney stones (5 patients), and diabetes (5 patients). A median of 27 pegloticase infusions (range: 9-84) were administered, with 8 of 9 patients receiving ≥12 infusions. Median number of infusions before and after initial GC discontinuation was 7 (range: 2-56) and 10 (range: 2-48), respectively. Pre-infusion steroids were re-started in 3 patients after a rise in sUA, with 1 regaining sUA response (patient 2) and 2 discontinuing therapy (patients 4 and 9). An additional patient had a loss of sUA response (patient 7) and discontinued, 1 patient discontinued due to hospitalization (patient 6), and 1 patient chose to discontinue therapy (patient 8). At the time of data collection, 4 patients remained on therapy (patients 1-3, 5). Eight patients had at least one AE (all deemed unrelated to treatment), including influenza, hypertensive crisis, and toe amputation. No IRs occurred.Conclusion:In this case series, 8 of 9 patients received 6 months or more (≥12 infusion) of pegloticase. These cases suggest that pre-infusion GC discontinuation may be possible in some patients treated with pegloticase (particularly those over 70 years). Further investigation exploring this concept is warranted, including evaluating the optimal time and conditions to discontinue pre-infusion GCs with pegloticase.References:[1]Sundy JS, et al. JAMA. 2011;306(7):711-720.[2]KRYSTEXXA (pegloticase) [prescribing information] Horizon.[3]Saag KG. Bull NYU Hosp Jt Dis 2012;70(Suppl 1):S21-S25.[4]Pillinger MH, et al. Bull NYU Hosp Jt Dis 2010;68:199-203.Disclosure of Interests:Veronica Newsome Speakers bureau: Abbvie, Anthony Amatucci Shareholder of: Horizon Therapeutics plc, Employee of: Horizon Therapeutics plc, Tim Stainbrook: None declared., Brian LaMoreaux Shareholder of: Horizon Therapeutics plc, Employee of: Horizon Therapeutics plc.

Background:The utilization of alternative modalities to deliver patient care during the coronavirus disease of 2019 (COVID-19) pandemic has catalyzed the widespread adoption and integration of telemedicine into routine practice. These shifts have afforded a pivotal moment to analyze existing guidelines, such as for hepatitis C (HCV), identify opportunities, and streamline algorithms for optimizing disease management in remote settings.Methods and findings: Toward furthering momentum for targeting global HCV elimination, our cross-specialty expert panel collaborated to develop a simplified treatment algorithm for use in telemedicine environments by non-specialist providers (Figure 1). This algorithm includes a framework for delivery of HCV treatment and recommendations for screening, pre-treatment evaluation, on-treatment monitoring, and post-cure follow-up. The use of telemedicine for HCV management is supported by multiple studies demonstrating similar cure rates, measured by sustained virologic response at 12weeks post treatment (SVR12), compared to standard, in-person clinic visits. No laboratory monitoring is necessary for the majority of patients taking pan-genotypic direct-acting antivirals (DAAs), further reinforcing the ease of remote management of HCV treatment. Touchpoints to support medication adherence can be conducted through a variety of technologies, including bidirectional text messaging, electronic portals, and telephone and/or video conferencing. Conclusion:Telemedicine thus offers a critical opportunity to expand identification, link to care, and treat persons living with HCV.

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